Erratum to nodal management and upstaging of disease. Initial results from the Italian VATS Lobectomy Registry

[This corrects the article DOI: 10.21037/jtd.2017.06.12.]

Spinal infection: state of the art and management algorithm

Spinal infection is a rare pathology although a concerning rising incidence has been observed in recent years. This increase might reflect a progressively more susceptible population but also the availability of increased diagnostic accuracy. Yet, even with improved diagnosis tools and procedures, the delay in diagnosis remains an important issue. This review aims to highlight the importance of a methodological attitude towards accurate and prompt diagnosis using an algorithm to aid on spinal infection management. METHODS: Appropriate literature on spinal infection was selected using databases from the US National Library of Medicine and the National Institutes of Health. RESULTS: Literature reveals that histopathological analysis of infected tissues is a paramount for diagnosis and must be performed routinely. Antibiotic therapy is transversal to both conservative and surgical approaches and must be initiated after etiological diagnosis. Indications for surgical treatment include neurological deficits or sepsis, spine instability and/or deformity, presence of epidural abscess and upon failure of conservative treatment. CONCLUSIONS: A methodological assessment could lead to diagnosis effectiveness of spinal infection. Towards this, we present a management algorithm based on literature findings

Elective cancer surgery in COVID-19-free surgical pathways during the SARS-CoV-2 pandemic: An international, multicenter, comparative cohort study

PURPOSE As cancer surgery restarts after the first COVID-19 wave, health care providers urgently require data to determine where elective surgery is best performed. This study aimed to determine whether COVID-19–free surgical pathways were associated with lower postoperative pulmonary complication rates compared with hospitals with no defined pathway. PATIENTS AND METHODS This international, multicenter cohort study included patients who underwent elective surgery for 10 solid cancer types without preoperative suspicion of SARS-CoV-2. Participating hospitals included patients from local emergence of SARS-CoV-2 until April 19, 2020. At the time of surgery, hospitals were defined as having a COVID-19–free surgical pathway (complete segregation of the operating theater, critical care, and inpatient ward areas) or no defined pathway (incomplete or no segregation, areas shared with patients with COVID-19). The primary outcome was 30-day postoperative pulmonary complications (pneumonia, acute respiratory distress syndrome, unexpected ventilation). RESULTS Of 9,171 patients from 447 hospitals in 55 countries, 2,481 were operated on in COVID-19–free surgical pathways. Patients who underwent surgery within COVID-19–free surgical pathways were younger with fewer comorbidities than those in hospitals with no defined pathway but with similar proportions of major surgery. After adjustment, pulmonary complication rates were lower with COVID-19–free surgical pathways (2.2% v 4.9%; adjusted odds ratio [aOR], 0.62; 95% CI, 0.44 to 0.86). This was consistent in sensitivity analyses for low-risk patients (American Society of Anesthesiologists grade 1/2), propensity score–matched models, and patients with negative SARS-CoV-2 preoperative tests. The postoperative SARS-CoV-2 infection rate was also lower in COVID-19–free surgical pathways (2.1% v 3.6%; aOR, 0.53; 95% CI, 0.36 to 0.76). CONCLUSION Within available resources, dedicated COVID-19–free surgical pathways should be established to provide safe elective cancer surgery during current and before future SARS-CoV-2 outbreaks

Elective Cancer Surgery in COVID-19-Free Surgical Pathways During the SARS-CoV-2 Pandemic: An International, Multicenter, Comparative Cohort Study.

PURPOSE: As cancer surgery restarts after the first COVID-19 wave, health care providers urgently require data to determine where elective surgery is best performed. This study aimed to determine whether COVID-19-free surgical pathways were associated with lower postoperative pulmonary complication rates compared with hospitals with no defined pathway. PATIENTS AND METHODS: This international, multicenter cohort study included patients who underwent elective surgery for 10 solid cancer types without preoperative suspicion of SARS-CoV-2. Participating hospitals included patients from local emergence of SARS-CoV-2 until April 19, 2020. At the time of surgery, hospitals were defined as having a COVID-19-free surgical pathway (complete segregation of the operating theater, critical care, and inpatient ward areas) or no defined pathway (incomplete or no segregation, areas shared with patients with COVID-19). The primary outcome was 30-day postoperative pulmonary complications (pneumonia, acute respiratory distress syndrome, unexpected ventilation). RESULTS: Of 9,171 patients from 447 hospitals in 55 countries, 2,481 were operated on in COVID-19-free surgical pathways. Patients who underwent surgery within COVID-19-free surgical pathways were younger with fewer comorbidities than those in hospitals with no defined pathway but with similar proportions of major surgery. After adjustment, pulmonary complication rates were lower with COVID-19-free surgical pathways (2.2% v 4.9%; adjusted odds ratio [aOR], 0.62; 95% CI, 0.44 to 0.86). This was consistent in sensitivity analyses for low-risk patients (American Society of Anesthesiologists grade 1/2), propensity score-matched models, and patients with negative SARS-CoV-2 preoperative tests. The postoperative SARS-CoV-2 infection rate was also lower in COVID-19-free surgical pathways (2.1% v 3.6%; aOR, 0.53; 95% CI, 0.36 to 0.76). CONCLUSION: Within available resources, dedicated COVID-19-free surgical pathways should be established to provide safe elective cancer surgery during current and before future SARS-CoV-2 outbreaks

VATS Biportal Left Pneumonectomy

Pneumonectomy is defined as the removal of the entire lung. This surgical procedure can be performed intrapericardially or extrapericardially and is associated with the radical dissection of the mediastinal lymph node without the resection of the mediastinal chest wall or the diaphragm. Pneumonectomy remains the main surgical choice for managing locally advanced lung cancer that cannot be treated using other anatomic lung resections like lobectomy or parenchyma-sparing procedures such as sleeve resection. The first successful pneumonectomy for cancer was performed by Evarts Graham in 1933 (1). In recent years, pneumonectomy has been performed for 10% of major lung resections. Despite improvements in surgical techniques and perioperative medical care, pneumonectomy is often associated with high perioperative morbidity and mortality (2–5). The video-assisted thoracoscopic surgery (VATS) approach used to perform lobectomy is widely accepted as a superior alternative to open thoracotomy. This is due to the following benefits: less postoperative pain, lower surgical morbidity, fewer complications, shorter hospital stays, and lower costs (6, 7). Video-assisted thoracoscopic pneumonectomy was first described by Walker in 1994 (8). After that, few reports of thoracoscopic pneumonectomy were published because the VATS approach is associated with technical difficulties (9–11). The purpose of this video is to show the authors’ experience performing a left pneumonectomy using the biportal VATS approach

L’EMPIEMA PLEURICO NEI PAZIENTI HIV-NEGATIVI CON DIPENDENZA DA SOSTANZE E/O ALCOOL: CARATTERISTICHE, TRATTAMENTO E RISULTATI IN UN SINGOLO CENTRO.

SCOPO DEL LAVORO L’empiema pleurico è una patologia temibile per gravità e frequenza che a volte è sottovalutata nei pazienti che abusano di sostanze stupefacenti e/o di alcool. Scopo del lavoro è studiare caratteristiche e trattamento di un gruppo di pazienti HIV-negativi con dipendenza patologica. MATERIALI E METODI Da Gennaio 2004 ad Aprile 2019 sono stati trattati chirurgicamente per empiema pleurico 121 pazienti (M/F: 81/40; età media 65 anni; range 21-83 anni) presso la nostra Unità Operativa. L’eziologia è stata principalmente parapneumonica con 103 casi (85%) e post-traumatica con 18 casi (15%). I pazienti sono stati retrospettivamente stratificati in due gruppi a seconda che avessero o no una dipendenza da sostanze e/o alcool fino a due anni prima (43 vs 78 pazienti – 36% vs 64%). Le caratteristiche dei pazienti con dipendenza sono state poi approfondite mediante analisi statistica univariata. Sono stati infine esclusi dallo studio i pazienti con empiema post-chirurgico e i casi dovuti a fistola bronco-pleurica. RISULTATI I casi di empiema pleurico parapneumonico sono stati 33 (77%; p=0,1) e post-traumatico 10 (23%; p=0,1) tra i pazienti con dipendenza patologica. L’età media era di 43 anni (range 21-56 anni) con un rapporto M/F di 28/15 (p=0,2). Ventiquattro pazienti (56%) sono stati sottoposti all’ingresso a posizionamento di drenaggio pleurico (p<0,05) e tutti i pazienti sono stati poi sottoposti, con buon esito, a intervento di empiemectomia e decorticazione (p<0,05) per persistenza di febbre e/o dispnea nonostante la terapia sistemica. La via di accesso finale è stata in tutti i casi la toracotomia (p<0,05), indipendentemente dallo stadio dell’empiema, a causa dell’estensione della flogosi. In 6 casi (14%, p=0,07) è stato necessario eseguire anche una lobectomia o wedge resection per la presenza di ascesso polmonare/micetoma (5 casi, 12%; p<0,05) o bronchiectasie (1 caso, 2%; p=1,00). All’analisi dei fattori di rischio la malnutrizione (BMI<19) è emersa come principale fattore con 15 pazienti (35%, p<0,05). Anche il diabete con 12 pazienti (28%, p<0,05) e la flebite con 4 pazienti (9%, p<0,05), associata o no ad ascesso nel sito d’iniezione della sostanza, rappresentano le comorbilità più frequenti in questo gruppo omogeneo di pazienti. È stato segnalato inoltre un caso di endocardite della valvola tricuspide (2%, p=0,4) e 4 pazienti erano HCV-positivi (9%, p=0,05) in assenza di cirrosi. CONCLUSIONI I pazienti con empiema pleurico e dipendenza presentano caratteristiche cliniche e comorbilità peculiari. L’intervento chirurgico di empiemectomia/decorticazione, più impegnativo in questi pazienti, è necessario per la persistenza di segni di sepsi anche dopo il posizionamento del drenaggio pleurico. La possibile spiegazione potrebbe essere, secondo noi, la presenza di malnutrizione e diabete oltre al già noto effetto immunosoppressore esercitato dagli oppiacei (eroina in primo luogo) e dall’alcool

Rapid Publications Growth Factor/Matrix-Induced Proliferation of Human Adult 0-Cells

Proliferation of human (J-cells in vitro is desirable for both transplantation and biological studies. In this study, human pancreatic islets obtained from cadavers were kept in tissue culture plates that favored cell attachment. When the cells attached to the matrix produced by the rat-bladder carcinoma cell line 804G, 5'-bromo-2'-deoxyuridine (BrdU) labeling increased from 4.7 ± 2.5 to 13.2 ± 2.2%, while cells simultaneously labeled for insulin and BrdU increased from 0 to 32%. Addition of the growth factor hepatocyte growth factor/scatter factor (HGF/SF) increased BrdU labeling to 17.5 ± 1.8 and the percentage of double positive (BrdU + insulin) cells to 69%. This is the first in vitro demonstration that human P-cells grown in monolayer culture are able to replicate when exposed to selected matrices and growth factors. These experiments add further evidence that HGF/SF is an important mitogenic agent for human p-cells. Diabetes 44:14581460, 199

Tips and tricks in video-assisted thoracoscopic surgery lobectomy

In 2012, open procedures represented 63% of the total number of lobectomies performed in our unit; in 2015, video-assisted thoracoscopic surgery (VATS) lobectomy numbers increased up to 66% of the total number of lobectomies performed. When carrying out the procedures, we followed the guidelines presented by the International VATS Lobectomy Consensus Group regarding indications, contraindications, preoperative investigations and conversions. In view of 280 VATS major lung resections from May 2012 to May 2016, we describe some tips and tricks that can be useful in this surgical technique, from general principles to single operative procedures

Cervico-manubrio-toracotomia secondo Grünenwald. Nostra esperienza in 3 casi di tumori dello stretto toracico superiore

Tumors of the cervical-thoracic area can be treated by the Grünenwald approach, which consists of an L-shaped cervical-manubrialthoracotomy without section of the clavicle. We used this access in three different tumors of the cervical-thoracic inlet: a tumor of T1 vertebral body, a tumor of the left superior sulcus, and a rare tumor originating from the root T1 of the brachial plexus. The first patient was a 39-years-old man with a somatic fracture of T1 and tumor invasion of the residual vertebral body by multiple myeloma. The 2nd patient was a 61-years-old man with a squamous cell carcinoma of S1 left upper lobe, infiltrating the parietal pleura and the chest wall, in the anterior-lateral part of the 2nd intercostal space. The 3rd patient was a 35-years-old woman with a glomic tumor originating from the T1 root of the right brachial plexus. The only post-operative complication was a modest diaphragm elevation in the 3rd patient, completely disappeared after 3-4 months. The 2nd patient is dead one year after the operation for cerebral metastases. The other two patients are presently in good conditions, without signs of relapse. Is our opinion the Grünenwald technique is technique for the treatment of tumors of the cervical-thoracic area allows a safe visibility of the anatomical structures without the necessity of a clavicle section